CTG INTERPRET WITH CARE

Fetal Monitoring in Labor: Two Acceptable Methods

Electronic
In active labor by convention needs to be continuous High false positives (K. Nelson 1996) Variable interpretations

Auscultated
Prescribed intervals Various devices but one recorded number Easy to interpret Intermittent Acceptable for high risk patients
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Why Auscultation?
Fewer C/Ss Simple Legally less Well liked by damningpatients interpretation Clear cut action/ clear response Allows changing Improves ability to entire environment ambulate in L&D Easier Decreases patient, family, nurse and physician anxiety

Electronic Monitoring: Later Outcome Nigel Paneth 1993 Clin.

Invest Med. Michigan St. Univ

Central hypotheses of EFM has never been tested

That is, that its use (EFM) can effectively prevent the... brain damaging birth asphyxia by timely intervention in labor.

For hypothesis to be true: Paneth (1993)

EFM must be reliable (inter-observer agreement on identity and meaning) EFM must be valid (patterns statistically linked with adverse neurological events) EFM and adverse outcome are related, specifically association is causal
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CRITICISMS TOWARDS CARDIOTOCOGRAPHY Insufficient understanding of the (patho-)physiologic background A number of technical pitfalls Differences in recording techniques Primarily qualitative information (pattern recognition) Lack of uniform classification systems Confusion due to the many influences on the fetal heart rhythm Substantial intra- and inter-observer variation regarding the interpretation Low validity, high incidence of false-positive findings Primarily screening method, too often applied as a diagnostic Leads to an increase in artificial deliveries Lack of agreement on how, when, and whom to monitor Contributes to medico-legal vulnerability
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ARGUMENTS AGAINST AUSCULTATION

Hard to do! No, not really! Requires more staff Shouldnt have to Does not meet standard of care Untrue! Will cause fetal harm, or CP? No more so than continuous EFM May miss something? -Such as?? Not legally defensible Hardly

THEN WHY DISCUSS CTG???

USEFUL IN HIGH RISK CASES.
STANDARDISED EVIDENCE BASED GUIDELINES ARE BEING LAID FOR CORRECT USE,INTERPRETATION , FURTHER DECISION MAKING & RECORD KEEPING.
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Appropriate monitoring in an uncomplicated pregnancy

For a woman who is healthy and has had an otherwise uncomplicated pregnancy, intermittent auscultation should be offered and recommended in labour to monitor fetal wellbeing. In the active stages of labour, intermittent auscultation should occur after a contraction, for a minimum of 60 seconds, and at least: every 15 minutes in the first stage every 5 minutes in the second stage. . Grade A Recommendation
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Indications for the use of continuous EFM

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GRADE B RECOMMENDATION
Continuous EFM should be offered and recommended for high-risk pregnancies where there is an increased risk of perinatal death, cerebral palsy or neonatal encephalopathy. Continuous EFM should be used where oxytocin is being used for induction or augmentation of labour.
REF:RCOG GUIDELINES
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ADMISSION CTG
Current evidence does not support the use of the admission CTG in low-risk pregnancy and it is therefore not recommended
Grade B Recommendation
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Selected High-Risk Indications for Continuous Monitoring of Fetal Heart Rate

Maternal medical illness Obstetric complications
Gestational diabetes Hypertension Asthma

Multiple gestation Post-date gestation Previous cesarean section Intrauterine growth restriction Oligohydramnios Premature rupture of the membranes Congenital malformations Third-trimester bleeding Oxytocin induction/augmentation of labor Preeclampsia Meconium stained liquor
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A Continuous EFM should be offered and recommended in pregnancies previously monitored with intermittent auscultation: if there is evidence on auscultation of a baseline less than 110 bpm or greater 160 bpm if there is evidence on auscultation of any decelerations if any intrapartum risk factors develop.
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Definitions and descriptions of individual features of fetal heartrate (FHR) traces

Baseline fetal heart rate :The mean level of the FHR when this is stable, excluding accelerations and decelerations. It is determined over a time period of 5 or 10 minutes and expressed in bpm.
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 Normal Baseline FHR 110160 bpm

Moderate bradycardia 100109 bpm Moderate tachycardia 161180 bpm Abnormal bradycardia < 100 bpm Abnormal tachycardia > 180 bpm

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The minor fluctuations in baseline FHR occuring at three to five cycles per minute. It is measured by estimating the difference in beats per minute between the highest peak and lowest trough of fluctuation in a one-minute segment of the trace

Baseline variability

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ACCELERATIONS

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DECCELERATIONS
EARLY
LATE VARIABLE

:
: :

Head compression
U-P Insufficiency Cord compression Primary CNS dysfn
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EARLY

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LATE

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VARIABLE

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Atypical Variable decelerations

With any of the following additional decelerations components:
loss

of primary or secondary rise in baseline rate slow return to baseline FHR after the end of the contraction prolonged secondary rise in baseline rate biphasic deceleration loss of variability during deceleration continuation of baseline rate at lower level
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Categorisation of fetal heart rate traces

Category Normal Suspicious Pathological Definition All four reassuring 1 non-reassuring Rest reassuring 2 or more nonreassuring 1 or more abnormal
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REDUCED

VARIABILITY

Hypoxia Sleep

Drugs

Extreme prematurity

CNS abno.

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TACHYCARDIA
Hypoxia Chorioamnionitis Maternal fever B-Mimetic drugs Fetal anaemia,sepsis,ht failure,arrhythmias

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SPECIAL PATTERNS
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Sinusoidal pattern
A regular oscillation of the baseline long-term variability resembling a sine wave. This smooth, undulating pattern, lasting at least 10 minutes, has a relatively fixed period of 35 cycles per minute and an amplitude of 515 bpm above and below the baseline. Baseline variability is absent Associated with Severe chronic fetal anaemia Severe hypoxia & acidosis
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SINUSOIDAL

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PSEUDOSINUSOIDAL

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CHECKMARK PATTERN

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SALTATORY PATTERN

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LAMBDA PATTERN

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SUSPICIOUS CTG CTG PATTERN

EARLY LATE

CAUSE
2nd Stage Uterine hypercontractily

CLINICAL MANAGEMENT NONE

Stop oxytocin Consider terbutaline sc Oxygen @ 8-10 l/min Left lateral decubitus Consider amnioinfusion (mild/mod v.d.)

VARIABLE

Cord compression

TACHYCAR DIA

Maternal Infection screen fever,tachycardia, Hydrate - crystalloids dehydration Stop tocolysis if 40 pulse>120

PATHOLOGICAL

FETAL SCALP BLOOD Ph (If facilities available)

FETAL SCALP STIMULATION TEST FETAL VIBROACAUSTIC STIMULATION TEST

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A Systematic Approach to Reading Fetal Heart Rate Recordings

Evaluate recording--is it continuous and adequate for interpretation? Identify type of monitor used--external versus internal, first-generation versus second-generation. Identify baseline fetal heart rate and presence of variability, both longterm and beat-to-beat (short-term). Determine whether accelerations or decelerations from the baseline occur. Identify pattern of uterine contractions, including regularity, rate, intensity, duration and baseline tone between contractions. Correlate accelerations and decelerations with uterine contractions and identify the pattern. Identify changes in the FHR recording over time, if possible. Conclude whether the FHR recording is reassuring, nonreassuring or ominous. Develop a plan, in the context of the clinical scenario, according to interpretation of the FHR. Document in detail interpretation of FHR, clinical conclusion and plan of management.
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 Prior to any form of fetal monitoring, the maternal pulse should be palpated simultaneously with FHR auscultation in order to differentiate between maternal and fetal heart rates. If fetal death is suspected despite the presence of an apparently recordable FHR, then fetal viability should be confirmed with realtime ultrasound assessment.
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RECORD KEEPING IN CTG

The date and time clocks on the EFM machine should be correctly set Traces should be labelled with the mothers name, date and hospital number Any intrapartum events that may affect the FHR should be noted contemporaneously on the EFM trace, signed and the date and time noted (e.g. vaginal examination, fetal blood sample, siting of an epidural)
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Any member of staff who is asked to provide an opinion on a trace should note their findings on both the trace and maternal case notes, together with time and signature Following the birth, the care-giver should sign and note the date,time and mode of birth on the EFM trace The EFM trace should be stored securely with the maternal notes at the end of the monitoring process.
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SOME INTERESTING CASES

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ACCELERATION OR DECCELERATION ???

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BASELINE BRADYCARDIA WITH ACCELERATIONS

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HALVING PHENOMENON

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EXCESSIVE VARIABILITY???

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GESTATIONAL DM ; NST ; 8:30am

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GDM ; CST ; 12 noon

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BLUNTED PATTERN WITH VARIABLE DECCELERATIONS CNS DYSFUNCTION

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Thank you
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